Vaginal Bleeding in Thai Childrendue to the Leech by lse16211

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									J Trop Med Parasitol 1999;22:77-9.                                                                                                   CASE REPORT




                  Vaginal Bleeding in Thai Children
                          due to the Leech

                                     Anek Aribarg, Vorapong Phupong

           Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University,
                          Rama IV Road, Pathumwan, Bangkok 10330, Thailand

                                                     Abstract

T      he leech is an important cause of vaginal bleeding among rural Thai children. This problem
       has neither been reported in Europe nor the United States. We describe 10 children aged
 between 5-10 years seen during a period of six years with a history of leech entering their vagina.
 There was variable severity of bleeding; three cases were mild and ceased spontaneously, six cases
 were severe and needed medical intervention, and one case was very severe and required blood
 transfusion. We propose a protocol for management of this problem which has resulted in a
 satisfactory outcome in all cases. If the bleeding ceases after a short period of observation, no
 further treatment is required. If the bleeding persists, the vagina should be examined and irrigated
 with physiological saline solution, to clean the bleeding point thoroughly and to ensure that the
 leech saliva is completely removed. Then, the vagina should be firmly packed with gauze, which
 is removed after 24 hours.

Keywords: vaginal bleeding, children, leech

Introduction
      The leech (Fig 1) is a tropical blood-sucking
aquatic parasite, genus Hirudo, class Hirudinea
[1] found in rural rivers and ponds of tropical
and subtropical countries. It has two suckers, a
cranial sucker housing a mouth, the bite mark
of which has been likened to a three-pointed
star and a caudal sucker involved in crawling
[1]. It can cause vaginal bleeding after entering
the vagina [2-5]. There has been no report from
either Europe or the United States as to it being
a cause of vaginal bleeding. We report our
experience of the leech as an important cause                Fig 1 Leech: a blood-sucking aquatic annelid
of vaginal bleeding in young Thai children,                         worm.
particularly in rural regions.

                                                             Methods
Correspondance:                                                   The cases were 10 children, aged between
      Vorapong Phupong, Department of Obstetrics and
                                                             5-10 years, who were under our management at
Gynecology, Faculty of Medicine, Chulalongkorn University,
Rama IV Road, Pathumwan, Bangkok 10330, Thailand;            the King Chulalongkorn Memorial Hospital,
E-mail: drvrp@hotmail.com                                    Bangkok, Thailand. The diagnosis was based on


Vol 22 (No. 2) December 1999                                      T H E J O U R N A L O F T R O P I C A L M E D I C I N E A N D PA R A S I T O L O G Y   77
Vaginal Bleeding in Thai Children due to the Leech


     a history of leech entering their vagina while                                              Discussion
     swimming in rivers or ponds. The cases were                                                       Thailand is an agricultural country in
     classified according to severity of bleeding and                                            Southeast Asia with a population of
     management. The study period was between                                                    approximately 60 million and a tropical rainy
     January 1, 1986 and December 31, 1991.                                                      climate. The leech (Fig 1) is a blood-sucking
                                                                                                 aquatic annelid worm, genus Hirudo, class
     Results                                                                                     Hirudinea [1] found in rural rivers and ponds of
          During a period of six years, January 1986 -                                           the central, southeast and northeast regions of
     December 1991 at the King Chulalongkorn                                                     Thailand. It is a temporary parasite to animals
     Memorial Hospital, Bangkok, Thailand, we saw                                                and may accidentally enter the vagina of
     10 children between the age of 5-10 years with                                              children and also adult women, swimming in
     a history of leech entering their vagina while                                              rivers or ponds causing variable degrees of
     swimming in rivers or ponds. The cases were                                                 bleeding. Its saliva contains hirudin, a specific
     classified according to severity of bleeding and                                            antithrombin [1, 6].
     management as shown in Table 1. There was                                                         There have been reports that an aquatic
     one case in which the bleeding was so severe                                                leech of the Northern Hemisphere (Limnatis
     that blood transfusion was required. In almost                                              nilotica) may be accidentally ingested with
     all cases, the leech dropped out of the vagina                                              drinking water and attach to the oropharynx,
     before the children and their parents noticed the                                           nasal passage, larynx and esophagus causing
     bleeding. In only one case, the leech was actually                                          anemia, epistaxis, asphyxia, dyspnea,
     found in the vagina during examination.                                                     hemoptysis, dysphagia and hematemesis, which
          The bleeding ceased spontaneously                                                      may be fatal in children [7-9]. There have also
     without any active intervention in three cases.                                             been reports about the leech causing ocular
     However, seven children were examined under                                                 injury [10]. The classic medical leech is Hirudo
     general anesthesia because the bleeding                                                     medicinalis [1, 11]. The leech has had an honored
     persisted. Their vaginas were washed with                                                   place in medicine and was used by Greek and
     physiological saline solution to remove blood                                               Moorish physicians for leech phlebotomy. Its
     clots. Special attention was taken to clean the                                             use extended into the late 1700s [1].
     bleeding points (due to leech bite marks)                                                         There have been a few reports in the English
     thoroughly to ensure that the leech saliva was                                              literature about the leech as a cause of vaginal
     completely removed. The vagina was then                                                     bleeding [2-5]. Our report on a series of 10
     packed with ribbon gauze and left for 24 hours.                                             children aged between 5-10 years was similar to
     In children, this procedure should be done under                                            the case reported by Lepage et al [3], but in
     general anesthesia.                                                                         contrast to other studies which found this


     Table 1 Vaginal bleeding in Thai children due to the leech: signs and management
             (N = 10).

              Number of cases                                                         Bleeding                         Management
                              3                                           mild & spontaneous                      conservative
                                                                          cessation
                              6                                           severe & persistent                     washing and packing under
                                                                          bleeding                                general anesthesia

                              1                                           very severe & active                    washing, packing under
                                                                          bleeding                                general anesthesia and blood
                                                                                                                  transfusion



78    T H E J O U R N A L O F T R O P I C A L M E D I C I N E A N D PA R A S I T O L O G Y                                    Vol 22 (No. 2) December 1999
                                                               Vaginal Bleeding in Thai Children due to the Leech


phenomenon in postmenopausal women [4, 5].            one should be aware of the leech as a cause of
This is probably due to the fact that young Thai      vaginal bleeding in children and also in adult
children have the habit of swimming in rivers         women if it occurs soon after bathing in a river
or ponds naked. The risk to them in having a          or canal. A protocol for management of leech
leech entering their vagina is greater than it is     entering the vagina has been proposed.
for adults.
     Similar to previous reports, the symptoms        References
in all cases were abnormal vaginal bleeding [2-        1. Segan JC. Leech. The dictionary of modern
5]. Most of our cases were diagnosed by a history         medicine. New Jersey: Parthenon; 1992.
of the leech dropping out of the vagina,                  p. 381.
accompanied by vaginal bleeding. There was             2. Prasad SB, Sinha MR. Vaginal bleeding due
only one case where the leech was actually found          to leech. Postgrad Med J 1983;59:272.
in the vagina during examination. We should            3. Lepage P, Serufilira A, Bossuyt M. Severe
suspect the leech as a cause of bleeding if a young       anemia due to leech in vagina. Ann Trop
girl has had a history of vaginal bleeding after          Paediatr 1981;1:189-90.
swimming in rivers or ponds.                           4. Mekasha A. Postmenopausal vaginal
     The management of this problem depends               bleeding due to vaginal wall leech
on the severity of bleeding. We propose a                 infestation. Ethiop Med J 1995;33:271.
protocol for management. If the bleeding ceases        5. Hailemariam B. Postmenopausal vaginal
after a short period of observation, no further           bleeding due to vaginal wall leech
treatment is required. However, if the bleeding           infestation. Ethiop Med J 1995;33:183-5.
persists for more than four hours or bleeding is       6. Munro R, Hechtel FO, Sawyer RT. Sustained
very severe, the vagina should be examined and            bleeding after a leech bite in the apparent
irrigated with physiological normal saline                absence of hirudin. Thromb Haemost
solution, to clean the bleeding point thoroughly          1989;61:366-9.
and to ensure that the leech saliva is completely      7. el-Awad ME, Patil K. Haematemesis due to
removed. Then, the vagina should be firmly                leech infestation. Ann Trop Paediatr
packed with gauze, which is removed after 24              1990;10:61-2.
hours. Blood replacement is given if indicated.        8. Campbell JR, Hart FL, Purnomo. Nasal leech
     Since 1991, no case of vaginal bleeding due          infestation of man. Trop Geogr Med
to leech has been seen at our hospital. This is           1987;39:94-5.
probably due to increasing water pollution in          9. O’Dempsey TJ. Tails of the unexpectorated:
the city area and many canals and waterways               experiences with leech infestation in
having been filled up for construction of land            childhood. Ann Trop Paediatr 1987;7:252-4.
transportation systems. Nevertheless, physicians      10. Alcelik T, Cekic O, Totan Y. Ocular leech
in rural hospitals are still faced with vaginal           infestation in a child. Am J Ophthalmol
bleeding due to leeches. There are no                     1997;124:110-2
epidemiological data on the number of cases in        11. Adams SL. The emergency management of
Thailand reported in the literature.                      a medicinal leech bite. Ann Emerg Med
     In conclusion, in tropical rainy climates,           1989;18:316-9.




Vol 22 (No. 2) December 1999                               T H E J O U R N A L O F T R O P I C A L M E D I C I N E A N D PA R A S I T O L O G Y   79
RESEARCH NOTE                                                                                                      J Trop Med Parasitol 1999;22:80-1.




     Efficacy of Three Methods in the Detection of Hookworm
               and Strongyloides stercoralis Infections


                                                   Sirima Kitvatanachai1, Vichit Pipitgool2

                                                        1
                                                 Faculty of Medical Technology, Rangsit University;
                                    2
                                        Department of Parasitology, Faculty of Medicine, Khon Kaen University



           Hookworm infection is usually detected by                                         (agar-plate) or fixed (Harada-Mori) with 10%
     the recovery of eggs or larvae in stool samples                                         formalin and centrifuged (700 g, 5 minutes) and
     [1]. Infection of Strongyloides stercoralis will be                                     re-examined. The formalin-ethyl acetate
     confirmed when a rhabditiform larva is seen in                                          concentration method was performed within
     a fecal smear but lightly infected cases might be                                       seven days after collection. Hookworm eggs or
     overlooked by the direct smear method. Filter                                           larvae and S. stercoralis larvae were carefully
     paper cultivation was considered as the best                                            observed.
     method to detect both hookworm and S.                                                         The number of positive samples for
     stercoralis infections [2, 3] because most of the                                       hookworm and Strongyloides infection detected
     larvae move downward to the bottom of the tube                                          by the three methods are shown in Table 1. The
     within seven days and survive for several days.                                         total positive cases for hookworm by the three
     Agar-plate cultivation was reported to be superior                                      methods was 56 (100%). By Harada-Mori
     to other techniques for the detection of S.                                             cultivation, the detection rate was 82.1% (46
     stercoralis infection in stool samples [4]; it also                                     positive cases). Agar-plate culture and formalin-
     required a shorter incubation period (two days).                                        ethyl acetate concentration gave lower detection
           This study aimed to evaluate the efficacy                                         rates of 58.9% and 30.4%, respectively. All
     of three methods which are recommended for                                              hookworm larvae were identified as Necator
     the diagnosis of these infections in the routine                                        americanus. S. stercoralis infection was best
     laboratory, namely formalin-ethyl acetate                                               detected by agar-plate culture method, since the
     concentration [3, 4], Harada-Mori culture [5] and                                       detection rate was 94.7%, while Harada-Mori
     agar-plate culture [3, 7, 8, 9].                                                        and formalin-ethyl acetate concentration
           The subjects were villagers in three villages                                     showed only 50.5% and 3.2%, respectively.
     (Nong Yaplong, Kudpeakormnue and Bueng-                                                       Results from this study supported the
     Sawang) of Khon Kaen province, Northeastern                                             proposition that agar-plate culture is superior to
     Thailand. Fecal examination by the three                                                the other techniques for the detection of
     methods was performed on 475 villagers whose                                            S. stercoralis infection [3, 7]. Koga et al [2]
     fecal samples were sufficient for the tests. For                                        mentioned the detection rate obtained by agar-
     Harada-Mori and agar-plate cultivation, the                                             plate cultivation as 1.7 times higher than the
     samples were cultured on the day of collection                                          filter paper method [3]. In the present study it
     and kept at room temperature (25-30 ˚C) for                                             was 1.9 times. Agar-plate culture should be
     seven days. The amounts of fecal sample used                                            performed after negative finding of suspected
     in the two cultivation methods were 2 gm and                                            cases in the routine laboratory and it is very
     4 gm respectively. The presence of larvae and                                           useful in laboratory research of strongyloidiasis
     free-living adults were observed under a stereo                                         and in epidemiological surveys. Drying the agar
     microscope. All negative samples were washed                                            plate before use and sealing the treated plate with



80    T H E J O U R N A L O F T R O P I C A L M E D I C I N E A N D PA R A S I T O L O G Y                                 Vol 22 (No. 2) December 1999
                                          Efficacy of Three Methods in the Detection of Hookworm and S. stercoralis Infections


Table 1 Detection rate of hookworm and S. stercoralis infections by formalin-ethyl
        acetate concentration (FAC), Harada-Mori culture and agar-plate culture
        methods.

                                                                                Detected cases
                               Total positive
                                                           FAC                  Harada-Mori                                    Agar-plate
  Hookworm                          56                    17                              46                                         33
  Detection rate                   100                    30.4                            82.1                                       58.9

  S. stercoralis                    95                      3                             48                                         90
  Detection rate                   100                      3.2                           50.5                                       94.7



adhesive tape as mentioned by Koga et al [2]                            M, Kaewkes S, Aunacharagan P,
could improve the efficacy of the agar-plate                            Wongratanacheewin S. Opisthorchis viverrini:
culture method and provide improved safety                              relationships between egg counts, worm
conditions for the technician performing the                            recovered and antibody levels within an
procedure. Harada-Mori cultivation is the best                          endemic community in Northeast Thailand.
method to detect hookworm infection. Not only                           Parasitology 1991;102:283-8.
the high detection rate but also other advantages                 5.    Harada Y, Mori O. A new method for
such as low cost, reusable equipment and the                            culturing hookworm. Yonago Acta Med
safe discard of used filter paper make this method                      1995;1:17.
the recommended one for hookworm infection.                       6.    Arakaki T, Iwanaga M, Kinjo F, Saito A, Asato
                                                                        R, Ikeshiro T. Efficacy of Agar-plate culture
References                                                              in detection of Strongyloides stercoralis
 1. Mangali A, Sasabone P, Syafruddin AK,                               infection. Parasitology 1990;76:425-8.
    Hasegawa H, Towa T, Kamimura K, et al.                        7.    Koga K, Kasuya S, Khamboonruang C,
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    Sukhavat K, Naoyoshe MI, Kinjikita T, et al.                  8.    Koga K, Kasuya S, Ohtomo H. How effective
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    1991;45:518-21.                                               9.    Hasegawa H, Miyagi I, Kamimura K,
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